Kessler, Chad S. MD, MHPE; Chan, Teresa MD; Loeb, Jennifer M.; Malka, S. Terez MD
Effective, easy communication between medical colleagues improves patient care and prevents errors. Physicians recognize this intuitively, and studies have backed them up by demonstrating the consequences of suboptimal communication skills. The Joint Commission on the Accreditation of Healthcare Organizations studied 2,000 sentinel events—preventable events that led to patient harm—between 2004 and 2012. Communication failure was a leading root cause of these events,1,2 responsible for 66% of reported sentinel events between 2011 and 2012.1 Yet, although effective communication with patients is well recognized as a key element of medical education, and several curricula exist to improve that skill,3,4 few programs train medical learners to communicate effectively with their colleagues.5,6
Safe, effective intercollegial communication in health care requires a sophisticated skill set that encompasses relationship building, argument structuring, clinical synthesis, cultural competency, and professionalism.3 The most common method of learning this critical skill set is by observation. Learners are often left to their own devices to ascertain what to communicate, when and how to communicate it, and how to establish rapport with involved parties. The PACT (Patient assessment, Assertive communication, Continuum of care, Teamwork with trust) project demonstrates that standardization of the transition process improves nursing handovers.7 Without standardization or formal instruction, these types of communications will tend to be radically inconsistent and destined to enable medical error.8,9 An opportunity exists within our medical training programs to enhance communication skills.10
Undergraduate medical training is a critical time for developing communication skills. The literature suggests that doctor–patient communication skills are taught more effectively during early clinical years and are best learned in clinical or simulated settings.11 Similarly, we infer that this is likely to be true for provider-to-provider communication skills as well.
Historically, early medical education emphasizes communication skills between physicians and patients (e.g., history taking).11 However, with increasingly complex situations requiring multidisciplinary teams, there is an ideal opportunity for improved training for communication between colleagues.12 The authors of this paper include attending physicians, residents, and medical students from multiple medical specialties (emergency medicine, internal medicine, surgery, and pediatrics). We recognize the importance of effective communication and the ramifications of communication skills for patient safety and for optimal patient care. We also acknowledge that communication skills may not develop naturally but can be taught and fostered through evidence-based educational models. The goal of this article is to explore existing models for improving provider-to-provider communication, with a focus on consultations, and to highlight the emergency department as a unique environment for training young clinicians in effective interprofessional communication skills.
Passing and Sharing Clinical Information During Handoffs
Communication between physicians constitutes a substantial and important piece of the patient care continuum. In the past few years, there has been an increasing amount of research seeking to enhance collaborative behavior and improve clinical communication skills amongst health care practitioners through the development of standardized communication tools.13–22 One area that has received specific attention recently is the “handoff”—the exchange that occurs when responsibility and authority over a patient’s care are transferred from one provider to another, for example, at shift change.9
Many studies have examined paradigms for improving the safety of these care transitions by suggesting mnemonics and other models to decrease interprovider variability.17,20,21,23 One example is the“I-PASS” (Illness severity, Patient summary, Action list, Situationawareness and contingency planning, andSynthesis by receiver) model, which includes actions for both the provider who is leaving and the one arriving. It reminds the first physician of important dataelements to communicate and also encourages the second physician to acknowledgement receipt oftheinformation and to give feedback—handoff safety elements recommended by the World Health Organization.17,20
A systematic review of handoff mnemonics published in Academic Medicine found that the mnemonics currently in use are too heterogeneous to allow for analysis of their efficacy.24 However, it seems intuitive that standardizing the content and format of these communication exchanges would improve the outcomes of these exchanges.
Consultations are similar to handoffs in that they are an exchange of patient data between two providers with a common goal of caring for a patient. It is theorized that standardizing these encounters as well may improve both the content of these interactions and the communication of critical elements. The mnemonics described above help to standardize these vital information exchanges and provide learners with a template and framework as they develop these critical communication skills.
In conclusion, the existing handoff literature emphasizes standardization and clinician training in communication skills as key elements in promoting safe and effective handoffs. Although consultations have several unique attributes, discussed in detail below, they require similar skill sets to handoff communications and would similarly benefit from improved standardization and communication skills education.
Distinguishing Consultations From Handoffs
Traditionally, consultations occur when one provider seeks the formal recommendations of a specialist regarding the care of a patient.25 Although they share key elements, such as communication of clinical data, consultations and handoffs are not directly equivalent. Although some consultations will lead to an eventual transition of care, they represent a different form of provider-to-provider communication. Instead of a series of team members performing the same task, as in a relay race, consultations call on different team members (sometimes newly recruited) to perform unique tasks, as in a baseball game. And unlike physicians involved in a handoff, who likely share a specialty, consulting physicians come with different training, perspectives, and skill sets. Their communications will inherently require more clarification and careful attention than do those between physicians in the same discipline.
Handoffs are also more likely to occur at dedicated times, such as shift changes. Consultations can occur at any time, and both the requesting and consulting physician may have limited time or other priorities, especially in high-stakes environments such as emergency departments and intensive care units. Doctors must quickly and effectively establish rapport, concisely convey patient data, and communicate a clear clinical question. Communication is further complicated by the fact that many consultations take place over the phone, which can present significant challenges in establishing rapport and ensuring that information is accurately heard and understood.26 This can be a daunting task for any physician, especially for those early in their training.
Kessler et al27–29 and Chan et al30 have both published recommendations based on analyses of consultations within the emergency department. These studies resulted in two models for effective consultation: the “5Cs” of consultation and the PIQUED method. There is a significant dearth of literature addressing the topic of consultations outside of the emergency department. One study, by Beaulieu et al,31 reports significant barriers to teaching family physicians and specialists to collaborate in the training environment due to the increasing distances between specialty and general medicine in the workplace and training arenas. There is one Cochrane systematic review on improving outpatient referrals from primary to secondary care.32 This review confirms the lack of quality studies on this topic. The few studies identified in this area suggest that structured referral sheets may be the only intervention that can affect outcomes.32,33 The Cochrane review also suggests that development of protocols for improving outpatient referral processes should include both referring and consulting physicians.32
There is even less research exploring the specific role of consultants in the consultation encounter. Sibert et al34 recognize the need for formal education in consultancy skills and describe key competencies for urology residents accepting outpatient consultations. They divided these skills into two general categories: (1) observable skills and (2) principles and attitudes. The specific elements are presented in List 1. However, no models or curricula currently formally address these specific communication skills used by consultants.
In summary, the unique challenges of consultations and the dearth of literature and educational templates for promoting effective consultations suggest a need for more emphasis on consultation communication skills. Studies of handoffs between junior residents show that content and comfort improve after formal training. It is likely that consultations would similarly improve with focused education and supervision during medical training.
Learning From Consultations in the Emergency Department
Nearly 40% of patient encounters in the emergency department will ultimately result in consultation between an emergency physician and a physician colleague (e.g., cardiologist or surgeon).25,35 These consultations are often high-stakes exchanges involving critically ill patients and time-sensitive decisions. Complex for even the most experienced clinicians, this task is particularly daunting for junior learners.16–18 Moreover, consultations are plagued by a lack of best-practice guidelines for communicating essential information.8 The emergency department also has some benefits as an arena for consultation learning because of the high volume of consultations and the 24-hour presence of attending physicians who can serve as role models and guides for theseexchanges.
A unique challenge of consultations is that they typically involve practitioners from different specialties, sometimes speaking different medical “languages” with nuanced differences in jargon, and coming from different medical cultural backgrounds. Moreover, differences in attitudes or actual management decisions between the consultant and the primary team may create confusion amongst learners. For example, an emergency department learner may call a surgery resident to assess a patient with intractable abdominal pain. The learner may be unsure how to proceed when the surgeon recommends referring the patient to an internal medicine team for observation instead.
There are several recent studies specifically examining the emergency department consultation process. In 2012, Kessler et al27 conducted a qualitative study to determine what emergency physicians and specialists considered the most important aspects associated with a successful consultation. That study resulted in the 5Cs model.27 Built on extensive review of medical and business literature, survey, and interview data, a new, standardized framework was developed for use in the emergency department. The key elements of “The Five Cs of Consultation” are Contact, Communication, Core question, Collaboration, and Closing the loop.27–29 The first column in Table 1 explains the elements of this model in further detail.
Chan et al30 explored the same topic, but with an educational focus. Physicians at multiple levels of training were asked how they felt junior learners should be taught consultation skills. The result was the PIQUED model, which includes six items: Preparation before the encounter, Identification of involved parties (speaker, listener, and patient), Questions (clinical question; answering questions), Urgency of the request (e.g., emergent consultation versus arranging outpatient follow-up), Educational modifications (e.g., acknowledging the role of senior physicians in teaching junior ones), and Debriefing and discussions after the consultation request. These are laid out in Table 1’s middle column.
Both of these tools have been derived with the intention of improving interphysician communication during the emergency department referral process, with an emphasis on the skills, attitudes, and behaviors of the referring physician. The 5Cs model focuses on desired elements of a consultation, and the PIQUED model has an explicit educational focus and is intended to serve as a teaching method for improving junior learner consultations. Table 1 describes the key components of these two models.
The 5Cs model is currently the most evidence-based model for improving physician communication during emergency department consultations. A randomized, controlled trial with the consultation model as the educational intervention was performed to assess the effectiveness of the 5Cs model.28 One resident cohort was trained using the 5Cs, whereas a control arm received standard training. Blinded specialist physicians used a global rating scale to determine the effectiveness of residents’ consultation skills and found that those trained with the 5Cs performed better during the consultation request.28
The PIQUED model expands on some of the elements present in the 5Cs model and allows specific focus on teaching and feedback. Therefore, the two models complement each other as a guide for learners performing consultations. The 5Cs model has an emphasis on collegiality and the desired aspects of a consultation exchange, and the PIQUED model supplies more specific guidance and includes explicit room for educational engagement. Taken as a whole, Table 1 is a synthesis of the 5Cs and the PIQUED models, their overlap, and how they might best complement each other.
In conclusion, these studies and the handoff literature suggest that trained consultants will perform better than untrained ones and that effective consultation skills can be taught and learned. Moreover, these models suggest that there are common skill sets that are required of referring physicians. As educators, we need to develop ways to better teach the process, likely starting with standardized protocols for inexperienced learners. Currently, there are only two evidence-based models for preparing and teaching consultations. These models may be combined into a comprehensive educational tool to be used in teaching junior learners effective consultation skills. The third column in Table 1 demonstrates how these two models may be combined to teach the emergency department consultation process.
Taking the Next Steps
A limitation of both of the consultation models is the emphasis on the referring physician’s behavior and the content of his or her report. Although the literature on in-hospital consultations is relatively sparse and focuses primarily on shaping the behavior of referring physicians, studies of telemedicine consultations describe the ways in which a consultation can be a collaborative and educational exchange. One example, described by Arora et al36 in the New England Journal of Medicine, highlights a telemedicine system that allows primary care providers to consult with medical specialists at a large academic center with the goal of allowing remote and isolated providers to provide expert care to patients infected with hepatitis C. That consultation model allows the consulting experts to not only offer management advice for individual cases but also educate and empower the primary care physicians to better care for their patients. The study demonstrated that this method of remote consultation improved treatment outcomes. That article highlights the powerful role a consultant can play, both as care providerand as educator and mentor for the requesting physician. An important area for future research is to study key behaviors, attitudes, and skills that consultants must have to effectively participate intheconsultation process, within the emergency departmentor beyond.
Models such as those described above clearly have the potential to improve performance and consistency. However, whether improved performance will lead to better patient outcomes still remains to be seen and is an area ripe for future research. We now suggest some specific areas of focus for future research and academic endeavors.
1. Validate the 5Cs and PIQUED models in other health care settings
We theorize that a standardized, evidence-based consultation model, such as the 5Cs or PIQUED, may reduce communication-related failures contributing to patient harm. However, both of these models were derived from research in the emergency department setting and must be studied and validated in other settings.
2. Integrate consultation models within educational curricula
Communication skills can clearly be improved with focused educational interventions. Teaching the consultation models described above, andsupervising their application, will improvestandardization and content of consultation communications and learner comfort with consultation skills. Further research can elucidate the best ways to apply the available consultation models within a medical curriculum.
3. Explore the effects of clinical communication on patient outcomes
To date, there has also been a dearth of literature addressing patient outcomes as a result of improved communication between health care providers. Although the association between adverse events and miscommunication is established, patient safety outcomes can be difficult to ascertain through clinical research. There is a need for more expert research to study the impact of a standardized consultation model on clinical outcomes and process measures of emergency department patients.33,37
4. Research the role of the consultant in effective consultations
Similarly, this is an opportunity or a call to action for further research concerning consultation and communication skills from the perspective of the receiving party—the consultant. The models discussed in this article have thoroughly outlined many methods in which the initial care provider can convey a synthesis of the situation to his orher colleagues. However, to date, few studies have looked at the behaviors, skills, and attitudes of the consultant. More research, such as that done by Wadhwa and Lingard,26 should be done to determine how consultants should conduct themselves during consultations so as to improve the referral–consultation process.
Making Communication Part of the Curriculum
Reforming communication practices begins with teaching our most junior learners to understand the best practices for communicating with other health care providers. In this era of health care reform, where significant attention is being paid to achieving better, safer, and more efficient care within fixed or constrained budgets, implementation of a curricular tool or set of tools that becomes integrated into our medical culture could have a positive impact on clinical outcomes with only a modicum of resource expenditure.
Whereas communication failures contribute significantly to the generation of adverse events, the use of standardized frameworks for encounters such as emergency department consultations is a giant step in the right direction; integrating these critical communicationand consultation skills into the undergraduate and graduate medical education curriculum is a game changer.
Acknowledgments: The authors would like to thank Dr. David Sklar and Dr. Marc DeMoya for their invaluable insight, thoughtful questioning, and critical review of this work.
Other disclosures: None.
Ethical approval: Not applicable.